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Clinical Quality and
Patient Safety Considerations
Session 163, February 13, 2019
Paul Cordts, M.D.
Acting Deputy Assistant Director, Medical Affairs
Defense Health Agency
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Paul Cordts, MD
Has no real or apparent conflicts of interest to report.
Conflict of Interest
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• Teamwork
• Swiss Cheese
• Errors and Preventable Harm
• Takeaways
• Q & A
Agenda
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• Describe the connection between EHR adoption and
quality care & patient safety
• Summarize the steps that the MHS is taking to ensure EHR
adoption, both legacy and MHS GENESIS, improves
quality care and patient safety
• Discuss the opportunities for enhanced quality and safety
as MHS GENESIS rolls out to all MTFs across the
enterprise
Learning Objectives
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this humerus]
[Image: Tech Support – What my friends
think…]
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TECH SUPPORT
[Doctors– What my friends think…]
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DOCTORS
[If doctors sketched logos…]
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[Image: Aviano Air Base C-17s w/ paratroopers]
[Image: Balad Iraq ER]
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[Image: Swiss cheese]
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1. Create a National Database of Usability and Safety
Issues
2. Establish Basic Design Standards
3. Unintended Harms Must Be Addressed
4. Simplify Mandated Documentation Requirements That
Affect Usability
5. Develop Standard Usability and Safety Measures So
Progress Can Be Tracked and the Market Can React
This Just In: 10 Years after HITECH Act
Source: JAMA.com, Feb 4 2019, “A Decade of Health Information
Technology Usability Challenges and the Path Forward”
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• Errors of Commission
• Errors of Omission
• Errors of Communication
• Errors of Context
• Diagnostic Errors
Top 5 Sources of Harm
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Errors of Commission
Risks /
Hazards
Harm
Errors of Commission
Errors of Omission
Risks /
Hazards
Harm
Errors of Omission
Errors of Communication
Risks /
Hazards
Harm
Errors of Communication
Errors of Context
Risks /
Hazards
Harm
Errors of Context
Diagnostic Errors
Risks /
Hazards
Harm
Diagnostic Errors
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• Patient Safety and Quality are complex
processes
• MHS Goal: Eliminate Preventable Harm
• HIT Can Connect the Dots, Close the Gaps,
Reduce Risk
• HIT Professionals are Integral Team Members
Key Takeaways
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Q & A
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For additional questions you can contact me at:
Dr. Paul Cordts <paul.r.cordts.civ@mail.mil>
Questions
Thank You
